In the United States young men who have sex with men are at disproportionate risk of HIV infection. In 2006, young men who have sex with men accounted from 53% of HIV infections among male and female ages 13-24 years (Mustanski, Garofalo, Monahan, Gratzer, & Andrews, 2013). Despite these alarming statistics, the majority of youth HIV prevention programs are designed for heterosexual youth, with the exception of community level Mpowerment Program (Mustanski et al., 2013). HIV prevention programs for young men who have sex with men should not be modified from prevention programs that were developed from heterosexual programs, because they face unique cultural, contextual, and developmental factors. Mustanski, et al, conducted a randomized clinical trial to evaluate the feasibility, acceptability and efficacy of an online, interactive, and highly engaging HIV prevention program, Keep It Up!
The Keep It Up! Program is a computer and internet based intervention that could overcome barriers such as cost effectiveness, dissemination, and implementation, which could increase potential interventions impact. Computer based interventions have been found to have a significant effect and increase in protective behaviors that are comparable to interventions delivered by human facilitators (Mustanski et al., 2013). Keep It Up! was designed to be an online intervention that could reach large numbers of young men who have sex with men of all racial and ethnic groups. The primary focus of this evaluation was to determine the practicality of recruiting and retaining participants, measuring the acceptability of the intervention, and efficacy of the intervention. The primary outcome was the number of unprotected sex acts and secondary outcomes included condom errors, HIV knowledge, and attitudes HIV risk and prevention.
The Keep It Up! Intervention includes seven modules completed in three sessions that are at least twenty-four hours apart. The information motivation behavioral skills (IMB) model of HIV risk behavior change was used to develop the intervention (Mustanski et al., 2013). The IMB model conceptualizes the psychological determinants of HIV behavior and provides a general framework for understanding and promoting prevention across diverse populations and prevention behaviors (Fisher & Fisher, 2000). The IMB model states that HIV prevention information, behavior, and motivation are fundamental in determining preventative behavior. Therefore, individuals must be well-informed, motivated to act, and possess the necessary behavioral skills so that they will more likely initiate and maintain preventative HIV behaviors (Fisher & Fisher, 2000). An innovative feature of the Keep It Up! intervention is that each model is based on a particular setting or situation that is relevant to young men who have sex with men, that includes developmentally appropriate health behavior change content (Mustanski et al., 2013).
Mustanski, et al., conducted a clinical randomized trial to determine the efficacy of the Keep It Up! intervention. The control group went through the same number of modules as the Keep It Up! intervention. This ensures that both groups had similar access to the internet for HIV related content, however, the control group modules did not take as long to complete as the Keep It Up! intervention. Unlike the intervention, the control group modules contained general information and were not tailored to user characteristics, non-interactive, and focused solely on HIV/STI facts (Mustanski et al., 2013). The control condition was intentionally designed to be comparable to existing internet based HIV information, so that Keep It Up! intervention could improve upon what is already available on online.
The evaluation of the Keep It Up! intervention showed that the intervention group had a small decrease from baseline to the 12-week follow up, compared to the control group which showed a significant increase in the rate of unprotected anal sex. The net effect of the Keep It Up! intervention was 44% lower rate of unprotected anal sex compared to the control group, when controlling for baseline rates (Mustanski et al., 2013). Mustanski, et al., saw condom errors were reduced in both arms. They also found that condom failures declined in the Keep It Up! intervention, however, increased in the control group. The purpose of this study was to assess the practicality, acceptability, safety, and effectiveness of an online HIV prevention program for young men who have sex with men. The purpose of the Keep It Up! intervention is to help young men who have sex with men remain HIV negative. Finding suggest that the Keep It Up! intervention can be delivered safely and with excellent participant retention and engagement.
Participant’s attitudes toward Keep It Up! were positive and the participants reported that the intervention helped them change their behaviors to reduce their risk of HIV. Finally, participants reported that they believed this intervention could help others like them (Mustanski et al., 2013).
The primary outcome was the 44% reduction in unprotected anal sex acts. The large reduction in unprotected anal sex acts exceeds those reported in meta-analyses of past HIV interventions for men who have sex with men (Mustanski et al., 2013). It also showed an increase in HIV knowledge and reduction in condom errors and failures. Therefore, the Keep It Up! intervention is a promising intervention for young men who have sex with men.
There are several limitations of this study. First, participants completed the modules under controlled conditions, which included staff reminder emails and phone calls and providing participants with incentives. Therefore, it is difficult to generalize how Keep It Up! would function outside of a funded controlled trial. Second, all outcomes were measured using self-reports, which can be biased. Finally, this was a relatively small sample size that was consistent with the purpose of conducting a preliminary randomized control trial. Based on the results of this study, further research should be conducted on the Keep It Up! intervention to test the efficacy of this intervention with a larger sample size and longer follow up periods (Mustanski et al., 2013). In the future it will also be important to measure outcomes that are not self-reported, like STI incidence. Finally, future studies should also explore the efficacy of the intervention in highly vulnerable sub-populations like young African American men who have sex with men.